Questions for Discussion by the Work Groups

I. THEMES

A. Demand

Subgroup 1: Assessing Demand

a. What should Demand include? Convincing people to use bednets or involving stakeholders in a decision-making role in shaping a community level bednet program?
b. What is the minimum information that a program planner needs to plan a strategy for demand creation?

• at the individual/community level
  
• at the regional/provincial level
  
• at the national level
  
• from the private sector

c. What tools and techniques can be used in each of these areas to accurately and efficiently measure demand?
d. What questions remain to be answered about demand creation?
e. How should the effectiveness of demand creation efforts be measured? what indicators should be used?

Subgroup 2: Approaches to Promoting/Sustaining Demand

a. Which mechanisms are typically most successful in promoting demand for bednets where benefits are more tangible? in promoting demand for personal insecticides where benefits are not necessarily so tangible?

• What is the role of mass media versus person to person campaigns?
  
• Should a program planner rely on individual demand or is a National Immunization Day model necessary?
  
• What do people need to hear in order to properly motivate them? e.g. should we be creating demand for malaria control or a good night=s sleep? How do you find out?

b. Are mechanisms/approaches to promoting demand in other sectors (e.g. family planning, water, child survival) relevant to creating demand for ITNs? In what ways? What do we have to learn from the experiences of other sectors?
c. To create demand for bednets, what should the message focus on?
d. What other options/vehicles for promoting demand deserve further attention and experimentation? For example,

• Ways to link demand for insecticides for bednets to demand for agricultural (animal, horticultural) insecticides?
  
• Ways to move from luxury product to product for larger market?

e. What do we want in the long term. In 10 years, where should people be getting their nets? Their insecticides for net treatment?

Subgroup 3: Targets for Demand Creation

a. How do you target key groups such as policy makers, community leaders, program implementors and members of households? What other groups should be targeted? What do we know about appropriate strategies for each of those groups? What do we know about how to differentiate messages as part of these strategies?
b. What's the role of the private sector in creating/sustaining demand? What has worked? What's the role of the private sector in paying for demand creation? Where have there been successful efforts to engage government and private industry to fund and implement IEC programs? what worked?
c. What are the different roles that the national government can take in creating and sustaining demand? What are examples of actions taken by national governments that support demand creation? What policies should a national government adopt in order to facilitate demand creation?

B. Affordability

Subgroup 1: Assessing Affordability at the Household level

a. What tools and techniques can be used by a program planner to gain a better understanding of issues of affordability at the household level, for example

• What constitutes "affordability" for consumer? How much disposable income is currently going into health maintenance? How much into Abad@ interventions?
  
• How are priorities set for household expenditures? How can these decisions best be influenced?
  
• How does seasonal availability of funds influence use for these kinds of purposes?
  
• What constitutes consumer Awillingness to buy?@ How can this be assessed?
  

b. What has been learned about how to deal with affordability issues in households with demand for multiple nets?
c. How should the effectiveness of efforts to deal with affordability issues be measured? what indicators should be used?

Subgroup 2: Approaches to Affordability Issues

a. Are mechanisms/approaches to household affordability in other sectors (e.g. family planning, water, immunizations) relevant to bednets and insecticides? In what ways? What do we have to learn from the experiences of other sectors?
b. What other options/vehicles for dealing with household affordability issues deserve further attention and experimentation? What are examples of Acreative financing@ that could make the unaffordable more affordable?
c. What approaches should be considered that include utilizing subsidies for nets/insecticides?

• Under what circumstances should nets or insecticides be subsidized?
  
• What lessons have been learned about how the level of demand would change if bednets were distributed free, subsidized or sold?
  
• If a government chose to subsidize the use of nets, what are different ways to subsidize? How could a government subsidize without actually spending money (e.g. tax incentives, eliminating tariffs)?
  
• What are the long range costs to the government of subsidizing bednets and/or insecticides? What techniques should be used to determine this?

Subgroup 3: Private Sector Role in Increasing Affordability

a. Can the private sector increase the affordability of their products? Should manufacturers cross-subsidize for nets and insecticides? To what extent is this happening already?
b. Are manufacturers committed to developing this market?
c. What determines the price of Bednets? What are the actual cost factors (e.g. shipping)? What experience is there in identifying/pursuing ways to reduce these costs (e.g. buy in bulk, manufacture closer to user)?
d. What can be learned from experiences in work with other sectors about how best to structure relationship between donors, the government, and the private sector as demand for bednets and personal insecticides increases and the market develops?

C. Accessibility

Subgroup 1: Assessing the Status of ITM Accessibility

a. What has been learned about the characteristics of existing distribution models that successfully ensure timely, affordable delivery of nets and insecticides? What currently works? Why does it work?
b. What are some simple, quick ways to assess the current level of bednet and insecticide accessibility?
c. What can the private sector teach us about distribution and sales in rural Africa? What is the role of the public and private sector in ensuring access? Does the commercial orientation of the private sector constrain its ability to reach poorer consumers?
d. What tools and techniques can be used to measure changes in consumer accessibility? What=s a standard measure for accessibility for nets, insecticides, and treatment?

Subgroup 2: Accessibility of ITMs at the Household and the Community Level

a. What tools and techniques can be used to assess household accessibility of bednets? Which households have access? Who has access within a household?
b. Typically if a household has access to only one net, preferential use will be by the adult male(s), a generally low risk population. What approaches can be used to increase access by pregnant women and children, a higher risk population?
c. Men and women typically play different roles in the initial purchase and continuing treatment of ITNs. What has been learned about the role of gender in encouraging accessibility?
d. How should the effectiveness of efforts to deal with accessibility issues be measured? What indicators should be used? (coverage? use?)

Subgroup 3: Increasing Accessibility of ITMs

a. Of the distribution options presented in the paper this morning, which is most relevant for bednets? How would these options need to be modified to better accommodate a role for the public sector? for the community? for NGOs?
b. Can the same distribution scheme be used to deliver both bednets and personal insecticide? If not, what are the options?
c. Are mechanisms/approaches to household accessibility in other sectors relevant to bednets and insecticides? In what ways? What do we have to learn from the experiences of other sectors? What can be learned from the experience of the private, consumer sales-oriented sector?
d. Most distribution models would seem to favor those who are most accessible. What has been learned about how to create distribution models that serve areas beyond existing schemes? Should there be a differentiated role for the public/private sector in answering this question?

D. Appropriate Use

Subgroup 1: Assessing the Appropriateness of ITNs as an Intervention

a. What information should be considered when assessing whether ITNs are an appropriate malaria control strategy in a given area? What tools and techniques should be used to gather this information? What criteria should be used to make the decision about whether ITNs are an appropriate malaria control strategy in a given area?
b. Is it sufficient for an ITN program to focus on individual access or is there always the need to develop a plan that has a community level impact?
c. What are appropriate measures of public health impact of ITN use? Some use the "percentage of target groups sleeping under adequately treated nets." Is this a satisfactory measure?
d. Who has responsibility for doing some kind of measure? When? At what cost? What does it take to get a credible answer? How can impact be tracked? At what cost?

Subgroup 2: Assessing Proper Use of ITMs

a. What is the minimum information that a program planner needs to know about current practices related to the correct use of bednets and insecticides before planning an ITN program?
b. What tools and techniques can be used to assess current practices related to correct use of bednets and insecticides?
c. How can the correct use of ITMs best be tracked over time? At what cost? What indicators should be used?

Subgroup 3: Successful Approaches to Promoting Appropriate Use

a. What are the most successful approaches to promoting the appropriate long and short term use of bednets and personal insecticides?

• What lessons have been learned by looking at existing users of bednets and insecticides?
  
• What are the major behaviors that need to be taken into account when making choices about approaches to promoting appropriate use of bednets and insecticide? What has been learned about what approaches most successfully bring about behavior change related to bednets and personal insecticides?
  
• In particular, what should the role of the community be in promoting effective use of bednets and personal insecticides?

b. What training components for promoters and educational components for uses can best foster appropriate and sustained use of bednets?
c. Can an ITM program be implemented independently of other public health activities or does it need to be integrated with other public health activities? Have free standing programs been successfully implemented?
d. Are mechanisms/approaches to use and appropriateness issues in other sectors (e.g. family planning, water immunizations) relevant to bednets and insecticides? In what ways? What can be learned from the experience of other sectors?

II. PROGRAMMATIC STEPS

Each group discussed:

1. What is known about assessment (or planning, or implementation, or monitoring and evaluation, depending on the group), when putting together an ITM program?
2. What is not known, i.e., what questions remain to be answered?
3. What actions need to be taken over the next one to two years to move forward to address the outstanding questions about what is not known?

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